Post written by Radhika Chavan, MD, DNB, from the Asian Institute of Gastroenterology, Hyderabad, India.
A 30-year-old woman underwent cholecystectomy 3 weeks earlier and developed abdominal pain, vomiting, and low-grade fever within 2 weeks of surgery. On contrast-enhanced computed tomography, a large lesion with an internal reticular pattern was seen in the gastro-hepatic region. She underwent gastroscopy, which revealed a large piece of gauze pad projecting through antrum and another end projecting through duodenum. A large braided snare was applied to the proximal part of the gauze pad, and gradually the entire gauze pad was pulled into the stomach. From the stomach we tried to remove gauze pad with rat tooth forceps but could not succeed because of significant resistance felt at the upper esophageal sphincter. Again, a braided snare was used, and with firm traction, the entire gauze pad was removed from the esophagus. On re-check endoscopy, a minor mucosal tear was seen at the upper esophageal sphincter, and a large fistulous opening was seen in the antrum. A nasogastric tube was kept and patient kept nil per orally for 48 hours. Re-check endoscopy on the third day showed significant healing of fistula. The patient was discharged on oral antibiotics and antacids. At 3-month follow-up, endoscopy showed scarring in antrum at the previous fistulous site and normal duodenal mucosa.
Gossypiboma is a rare and serious adverse event that develops after surgery because of inadvertent retention of cotton gauze. Gossypiboma is usually managed by repeat surgery. Repeat surgery in such a patient not only increases the morbidity but the mortality as well. Few case reports demonstrate combined endoscopic and laparoscopic removal of gossypiboma. Complete endoscopic removal can be attempted for a gossypiboma with extension into the gastrointestinal lumen.
Gossypiboma can migrate into the stomach, ileum, colon, or bladder with or without any apparent opening in the wall of these luminal organs. It can lead to obstruction, perforation, and fistula formation. In a selected group of patients with luminal gossypiboma, even with entero-enteric fistula, endoscopic management can be tried. Slowly and with firm traction, the entire gossypiboma can be removed with the endoscope. The advantage of endoscopic removal of gossypiboma is that it allows oral intake early and decreases the hospital stay and overall cost of treatment.
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